INITIAL EVALUATION

General Information

Patient’s Initials: C.S

Age: 25 y/o
Sex: F
Address: Sta Lucia, Pasig City
Civil Status: Single
Citizenship: Filipino
Handedness: Right-handed
Occupation: Basketball Player
Religion: Roman Catholic
Referring Unit: Orthopedic Unit - Mission Hospital
Referring Dr: K.L
Rehab Dr: T.P
Date of Consultation: April 4, 2024
Date of Referral: April 4, 2024
Date of I.E.: April 5, 2024
Diagnosis: ® ACL Tear Injury S/P Reconstruction

History of Present Illness (HPI):

Present condition started ~1wk prior to PTIE when pt was in basketball tournament and
was about to jump and attempt to get the ball from the opponent, the pt landing from a
jump resulting her ® knee to hyperextend. Pt felt extremely dull aching pain PS 10/10
and felt her ® knee to pop out. Pt also reported that she cannot stand and put weight on
R knee as she felt that her knee gave way. Pt’s coach and co-player immediately went
to the pt and noticed a swelling on her ® knee. The coach immediately put an ice pack
over the affected areas. Pt was then placed on a stretcher and was immediately brought
to the nearest hospital via ambulance. Ice pack was placed on pt’s ® knee. Upon
arrival, the pt was given Oxycodone (see meds taken) to alleviate pain PS 7/10. Dr. T.P
performed a Lachman test and pt was positive for ACL tear but Dr.T.P also ordered for
an MRI (see ancillary procedures) to know the extent and specificity of the injury. Pt was
advised to rest.

~ 5 days PTIE, the results of an MRI showed that the pt has a ® Knee ACL complete
tear (grade 3) accompanied by torn MCL. Dr. T.P also ordered for CBC (see laboratory
procedures).

~ 3 days PTIE, pt’s CBC showed that it was WNL. Pt was cleared for swelling and
surgery was performed on that day. Pt underwent arthroscopic ACL reconstruction using
semitendinosus gracilis tendon autograft. Dr. T.P prescribed a tri panel knee splint (knee
immobilizer brace) to be worn in the few postoperative weeks while using crutches
during ambulation.

~ 1 day PTIE, Dr. T.P allowed the pt to PWB on the affected leg. Dr T.P prescribed
Acetaminophen (see medication below). Pt is then referred to the outpatient
rehabilitation that focused on inc ROM, inc ms strength on ® LE and gait training.

At present, the pt is still experiencing intermittent dull aching pain PS 5/10 on ® knee,
swelling and pt also present of joint effusion. Pt also has dec ms strength and dec ROM
on ® knee flexion and knee extension.

ANCILLARY PROCEDURE
Diagnostic Date Findings Significance
Procedure

® Magnetic March ® Knee ACL Reconstruction of ®

Resonance 29,2024 complete tear knee ACL is indicated in
imaging (MRI) of (grade 3); Torn MCL order to achieve pt’s
the knee desire level of function
as an athlete

LABORATORY PROCEDURES
Laboratory Date Findings Significance
Procedure

Complete blood March WBC: 6,500 cells/mcL Normal; pt. is

count (CBC) 31,2024 RBC:4.5 million cells/mcL cleared for
Platelets:350,000 surgery.
platelets/mcL
Hgb:13 gm/dL
Hct: 40.1%
MCV:90

PRESENT MEDICATIONS
Drug Name Indication Dosage Frequency/Mode
of Transmission

Oxycodone For moderate-to-severe 10mg b.i.d/ oral

pain

Acetaminophen for minor pain 500mg PRN/oral

PMHx
➢ (+) Hospitalization, surgical reconstruction of ® ACL (2024)
➢ (+) Trauma on ® knee
➢ (-) prior injury to ligaments & menisci of (B) knees
➢ (-) HTN
➢ (-) DM
➢ (-) Cardiopulmonary Dse

FMHx
Medical History Maternal Paternal

HTN (-) (-)

DM (-) (-)

Cardiopulmonary Dse (-) (-)

ACL Injury (-) (-)

PSEHx
➢ Pt. has a type A personality she is competitive, organized, and poactive
➢ Pt. has an active lifestyle & attends basketball training 5 days/wk & goes to the gym
3 days/wk
➢ Pt. is a non-cigarette smoker
➢ Pt. is an occasional drinker (3 cans of beer/occasion)
➢ Pt. prefers eating foods high in proteins (such as chicken breasts, egg), low in
carbohydrates (such as beef, nuts, yogurts), and takes workout supplements (high
in protein and fibers)
➢ Pt. enjoys playing video games for 2 hours and running with her dogs for 1 hour (~
5 km) during weekends

Work Situation:
➢ Pt. trains at the Pasig Multi-purpose complex (~20 mins travel time from home)
➢ Pt. trains for 5-6 hrs/day; 5 days/wk
➢ Pt. tends to overtrain sometimes by exceeding their required time of training during
championship-level games.
➢ The floor of the basketball court is made up of vinyl.

Home Situation:
➢ Pt. lives in a 2-storey house inside a subdivision
➢ Gate ↔ Front Door ~ 10 m
➢ Bed Room ↔ Living Room ~ 2 flights of stairs, 15 m
➢ Bed Room ↔ Kitchen ~ 2 flights of stairs, 20 m
➢ Bed Room ↔ Bathroom ~ 6 m
➢ Ground Floor ↔ 2nd floor ~ 2 flight of stairs
➢ Stairs: Unilateral Railing
 ➢ Height of stair steps ~ 0.1 m
➢ Depth of stair steps ~ 0.15 m

SUBJECTIVE:
Pt. c/c: “Sumasakit po yung kanang tuhod ko at parang nanghihina lalo na pag
sinusubukan kong maglakad at kapag binigyan ko ng bigat itong kanang tuhod ko”

PT Translation: Pt ℅ of dull aching pain (PS 5/10) on ® Knee 2° weakness especially

when trying to walk and give some weight on ® LE

Pt’s Goal: Pt wants to regain her strength to be able to play basketball s difficulty and
experiencing pain.

OBJECTIVE:
I. Vital Signs
Before During After

BP 120/80 mmhg 110/80 mmhg 120/80 mmhg

PR 83 bpm 85 bpm 83 bpm

RR 18 cpm 17 cpm 17 cpm

Temp. 36.5°C 36.5°C 36.5 °C

Findings: VS are WNL.
Significance: For baseline purposes and precautionary measures during exercise
prescription

II. Ocular Inspection

➢ Pt. Amb c AD
➢ Mesomorph
➢ A/C/C x3
➢ (+) R Tri panel knee splint
➢ (+) 3 surgical wound on R knee c transparent wound dressing
➢ (+) ¼ inch wound length
➢ (+) Redness on R knee
➢ (+) Swelling R knee
➢ (-) Scars
➢ (-) Bruises
➢ (-) Muscle Atrophy on R LE
➢ (-) Trophic skin changes on R LE
➢ (-) Deformities on R LE
III. Palpation
➢ Normothermic on all exposed area exc.
➢ Hypothermic on R ant knee
➢ (+) Grade 2 tenderness on R ant knee
➢ (+) Muscle spasm on R quads & hamstrings
➢ (-) Edema on B LE
➢ (-) Stiffness
➢ (-) Crepitus
➢ (-) Muscle Guarding

SPECIAL MEASUREMENTS
I. ROM
All joints of (B) UE/LE are WNL, actively and passively done in pain free with normal
End feel, except for the following:
Motion (N) AROM PROM Difference End-feel
Values
AROM PROM

R knee flexion 0-135° 0-60° 0-70° 75° 65° Empty

R knee 135-0° 60-20° 60-20° 20° 20° Empty

extension
Findings: (+) LOM towards flexion and extension of R knee d/t pain
Significance: LOM may contribute to pt’s difficulty in performing activities like bed
mobility, transfers, sit to stand activities

II. MMT
All major muscle groups on (B) UE & LE are grossly graded 5/5 except for the following:
Muscle Group Grade

® Knee Flexors 3/5

® Knee Extensors 3/5

Findings: Pt. has fair muscle strength on ® knee flexors & extensors
Significance: Pt.’s will be having difficulty in performing proper gait mechanics, affects
ADLs such as standing, LE dressing, ascending and descending stairs.

III. Limb-Girth Measurement

Landmarks (L) (R) Difference

2 in above patella 42 cm 47 cm 5 cm

Medial joint line 35 cm 37 cm 2 cm

 2 in below the 33 cm 36 cm 3 cm
patella
Findings: Pt. has swelling on (R) Knee
Significance: Swelling is precaution for PT treatment

IV. GAIT ANALYSIS

R L

Stance Phase

▪ Heel strike + +

▪ Foot flat + +

▪ Mid-stance - +

▪ Heel off - +

▪ Toe off - +

Swing Phase

▪ Acceleration - +

▪ Mid-swing - +

▪ Deceleration - +
Findings: Pt. presents with antalgic gait. Causing her to limp and walk abnormally 2° to
pain (PS: 5/10). There was insufficient hip and knee flexion and ankle plantarflexion
observed during the swing phase. There is dec. (B) arm swing, slowed amb. speed,
dec. stride length and step length; dec. (R) step width; lack of a heel-toe sequence c
forward progression.
Significance: Precaution for the (R) knee to buckle during PT Mx is indicated. Balance
& fall prevention exercises are indicated. (R) knee flexor strengthening is also indicated.

V. BALANCE AND TOLERANCE TEST

Starting Activity Findings Significance
Position

Standing Walking backwards Functional Identifying if there

are any deficits in
Running forward c 20° Functionally poor dynamic postural
knee flexion control of the pt.
Precautionary
 Squat up to 20°-30° Functionally poor measure for PT Mx.
Balance & fall
Jump, lifting the body of Functionally fair prevention exercises
the floor are indicated.

VI. OUTCOME MEASURE TOOL:

“ACL-Return to Sports After Injury (ACL-RSI) Scale”
Findings: Pt. is scared of being unable to participate in social or recreational
activities due to the injury. Pt. also felt fear of reinjury or uncertainty about the future,
especially regarding their ability to return to normal activities or sports, can lead to
anxiety and stress.
Significance: Measures the psychological responses of the pt. to return to sport
involving emotions, confidence in performance, and risk appraisal.

ASSESSMENT:
PT Diagnosis: Pattern 41: Impaired Joint Mobility, Motor Function, Muscle
Performance, and Range of Motion Associated With Bony or Soft Tissue Surgery.

PT Impression:
Pt was Dx with ACL Injury S/P Reconstruction, associated with difficulty performing
sports activities and performing ADLs such as ambulation activities. Pt has pain (PS
5/10) and swelling on (R) knee. Pt was prescribed to wear a rehabilitative brace after
ACL Reconstruction, PT referral is indicated, Pt has ms strength of (MMT ⅗), Pt will
have a PT rehabilitation for 3 sessions/wk.

Rehab Potential: Patient has Good prognosis as to functional recovery because

of the following reasons:
1. Pt’s is cooperative in PT Mx.
2. Pt. prompt medical attention
3. Pt has no hx of any injuries in B knees.

Problem List:
1. Pt has LOM on AP of ® Knee.
2. Pt. has muscle weakness on knee flexors d/t surgery.
3. Pt. has a widespread tenderness on ® knee.
4. Pt felt a pop or crack while ambulating with crutches.
5. Pt has pain (PS: 5/10) and swelling on R knee.

STG:
1. Pt. will increase ROM on knee flex. & ext. from 60 deg to 100 deg in 8 PT
sessions.
2. Pt.’s MMT grade will inc. from grade ⅗ to grade 5/5 in 8 PT sessions.
3. Pt.’s will have a dec. tenderness from Grade 2 to Grade 0 in 5 PT Sessions.
4. Pt.’s intermittent dull aching pain (PS:5/10) will be dec. to PS: 2/10 in 6 PT
 Sessions.
5. Pt’s will actively ambulate with crutches pain free and without feeling of
awkwardness due to popping or cracking of knee in 8 PT sessions.

LTG:
Preventive: Within 3 months of PT session c 3 sessions per week, Pt. will be able to do
all the prescribed exercises and prevent further complications associated with the
condition.

Rehabilitative: Within 2 months of PT session c 3 session per week, Pt. will be able to
get back her ROM from 60deg of flexion & extension to WNL on R knee, Pt muscle
strength from ⅗ to 5/5 on R knee flexors and extensors.

Participative: Within 3 months of PT session c 3 sessions per week, Pt. will be able to
get back from sports and social activities that require motor skills.

PLAN:

PT Mx:
➢ Cryotherapy on ® knee x 5 mins.
➢ Conventional TENS on ® knee x 20 mins
➢ Heel slides on the ® leg x 15 s/h x 10 reps x 2 sets
➢ Hamstring Curl x 10 reps x 2 sets
➢ Setting Exercises of the ® quadriceps and hamstrings x 7 s/h x 10 reps x 2 sets
➢ SLR on ® leg x 10 reps x sets
➢ Amb. training c crutches

Home Instructions/ Education

➢ Avoid engaging in work, sport, and recreation activities that place high demands
on the knee.
➢ Do not sleep with a knee in a flexed position, sleep with your knee in a straight
position with a towel under your heel.
➢ Pt. should be educated on prevention of ulcers by proper positioning and turning
every 15 mins.

Home Exercise Program

➢ Ankle pumps on (B) ankle 10 reps
➢ (B) Heel Raises 10 reps
➢ Wall squats 7 s/h x 10 reps
Prepared by:

____________________
Alagon, Lani Joy
PT Student
2023-2024

____________________
Flores, Genevie
PT Student
2023-2024

____________________
Fernandez, Charles Kenneth
PT Student
2023-2024

____________________
Gonzaga, Sean Hailey
PT Student
2023-2024

____________________
Guinto, Aldrinne Joshua
PT Student
2023-2024

____________________
Manalang, Crystal Ann L.
PT Student
2023-2024

____________________
Tibay, Mia Justine B.
PT Student
2023-2024